Abdominal Wall Reconstruction Utilizing the Combination of Absorbable and Permanent Mesh in a Retromuscular Position: A Multicenter Prospective Study.

Background Optimal mesh reinforcement for abdominal wall reconstruction (AWR) in complex hernias remains questionable. Use of biologic, absorbable and synthetic meshes has been described. The idea of using an absorbable mesh (AM) under a permanent mesh (PM) in a retromuscular position may help in these challenging situations. Methods Between 2011 and 2016, consecutive patients undergoing open AWR utilizing an AM as posterior layer reinforcement and configuration of a large PM were identified in a multicenter prospectively maintained database in four hospitals. Main outcomes included demographics, ventral hernia classifications, perioperative data, complications and recurrences. Results A total of 169 complex incisional hernias were analyzed. Mean age was 60.9, with mean body mass index 30.7 (range: 20–46). Location of incisional hernias (IH) was: 80 midline, 59 lateral and 30 midline and lateral. 78% were grade I and II in Ventral Hernia Working Group classification. 52% of patients were discharged with no complication. There were 19% seromas, 13% hematomas, 12% surgical-site infection and 10% skin dehiscence. Only partial mesh removal was necessary in one patient. After a mean follow-up of 26 months (range 15–59), there were five (3.2%) recurrences. Reoperations on patients showed a band of fibrosis separating the peritoneum from the PM. Conclusion The combination of AM with very large PM in the same retromuscular position in AWR seems to be safe. The efficacy with recurrence rates below 4% in complex midline and lateral IH may be explained by the use of larger PMs that are extended and configured with the support of AMs. Reoperations on patients have confirmed the previous experimental reports on the use of the AM.pre-print1351 K

Modulación de la respuesta inflamatoria esplácnica en la colestasis microquirúrgica experimental con ketotifén

"Introducción". El desarrollo de fibrosis hepática e hipertensión portal en múltiples hepatopatías crónicas de etiología diversa es un proceso multifuncional, mediado por células inflamatorias que, al liberar mediadores fibrogénicos, activan a las células estrelladas y a los miofibroblastos. La administración de ketotifén, un fármaco estabilizador de células cebadas, que inhibe la síntesis y liberación de sus mediadores inflamatorios, en un modelo experimental microquirúrgico de colestasis extrahepática, al inhibir la degranulación de las células cebadas, disminuiría la liberación hepato-intestinal de mediadores inflamatorios y profibrogénicos, consiguiéndo así reducir tanto la respuesta inflamatoria esplácnica como la fibrosis biliar secundaria a colestasis "Material y Métodos". Para verificar ésta hipótesis se han estudiado en ratas Wistar pseudo-operadas (PSO; n=15) y con colestasis extrahepática microquirúrgica (CMQ; n=20) la presencia de ascitis, de vasculopatía venosa mesentérica, de hipertensión portal y el desarrollo de circulación colateral portosistémica. Se cuantificaron las concentraciones séricas de parámetros de función hepato-biliar por fotocolorimetría, así como los niveles de mediadores pro- y anti-inflamatorios en el ileon terminal, los ganglios linfáticos mesentéricos y el hígado mediante técnicas de inmunoensayo enzimático de tipo enzyme-linked immunosorbent assay (ELISA). Por último, se realizó un estudio histopatológico hepático y tinción de Rojo Sirio para cuantificar el area de fibrosis hepática. Los mismos parámetros se evaluaron en ratas PSO (n=20) y en ratas con CMQ (n=20) a las que se administró ketotifen (10 mg/kg/día; v.o.) desde las 24 horas previas a la intervención y durante todo el período postoperatorio de 8-9 semanas "Resultados": Las ratas con colestasis mostraron ascitis, aumento de la presión portal (p<0.001), vasculopatía venosa mesentérica y desarrollo de circulación colateral portosistémica con hepato-esplenomegalia (p<0.001) y atrofia testicular (p<0.01). Además, en las ratas colestásicas se observó hiperbilirrubinemia (p<0.001), aumento de la fosfatasa alcalina (p<0.001), ácidos biliares (p<0.001), aspartatoaminotransferasa (p<0.001), colesterol (p<0.001), triglicéridos (p<0.05) y lipoproteinas de baja (LDL; p<0.001) y muy baja densidad (VLDL; p<0.001)respecto de las ratas pseudo-operadas. Por el contrario, en éstas ratas se demostró hipoproteinemía (p<0.001) e hipoalbuminemia (p<0.001) y disminución de la concentración sérica de lipoproteinas de alta densidad (HDL; p<0.05). Respecto de la respuesta inflamatoria esplácnica, en las ratas con colestasis se observó aumento de catalasa en el íleon (p<0.01) y disminuyó en los ganglios linfáticos mesentéricos, glutation-transferasa y glutation-peroxidasa disminuyeron también en el íleon y en el hígado, TNF-α aumentó en ileon y ganglios linfáticos mesentéricos, IL-1β disminuyó en ileon (p<0.05) y ganglios linfáticos mesentéricos y aumentó en el hígado (p<0.05), IL-10 aumentó en ileon (p<0.05), IL-4 aumentó en el ileon (p<0.05) y en el hígado, IL-13 e IL-17A aumentaron en el ileon y disminuyeron en los ganglios linfáticos mesentéricos, la proteina quimioatractante de macrofagos (MCP-1) aumentó en el ileon (p<0.05) y disminuyó en los ganglios linfáticos mesentéricos y en el hígado (p<0.01), el factor de crecimiento transformador-beta1 (TGF-β1) aumentó en el ileon y en el hígado y disminuyó en los ganglios linfáticos mesentéricos. En el estudio histopatológico hepático de las ratas colestásicas se observó necrosis y apoptosis hepatocitaria asociado una intensa proliferación epitelial biliar y fibrosis (p<0.001). El tratamiento con ketotifen en las ratas con CMQ redujo la ascitis, el peso corporal, la hepato-esplenomegalia y las concentraciones séricas de bilirrubina total y directa y de ácidos biliares, en tanto que aumentó los niveles séricos de proteinas totales y de lipoproteinas de alta densidad (HDL). Respecto de las concentraciones de mediadores inflamatorios en el área esplácnica, ketotifen disminuyó los niveles de MCP-1 en el higado, TNF-α en el ileon y en el hígado (p<0.05) e IL-17A e IL-1β en el ileon (p<0.05) en tanto que aumentaron las concentraciones de IL-4 e IL-10 en el hígado y de IL-13 en el ileon. "Conclusión". La relevancia del presente trabajo de investigación se fundamenta en la posible extrapolación de los resultados obtenidos a la clínica humana, en la cual la cirrosis, de diferentes etiologías, comporta una elevada morbi-mortalidad en la actualidad. En particular el tratamiento anti-inflamatorio con ketotifen podría ser de utilidad para reducir las complicaciones secundarias a las hepatopatias crónicas de origen biliar. [ABSTRACT] "Introduction": The development of hepatic fibrosis and portal hypertension in most cases of cronic hepatic illness from diverse etiologies is a multifunctional process, mediated by inflamatory cells that, when liberate they fibrogenic mediators, they activate star cells and miofibroblasts. Ketotifen, a drug that stabilizes mast cells and inhibits synthesis and liberation of inflamatory mediators, was administered in a cholestasis hepatic microsurgery experimental model, where it inhibits mast cell degranulation which reduces hepatic-intestinal inflammatory and profibrogenics mediators. This achieved a decrease in the splacnic inflamatory response as biliar fibrosis secondary to cholestasis. "Material and Methods": In order to verify the hypothesis about the presence of ascitis, venous mesenteric vasculopaty, portal hypertension and the development of portosistemic colateral circulation has been studied in sham-operated Wistar rats (SO; n=15) and in rats with microsurgery extrahepatic cholestasis (MC; n=20). Hepatobiliar function establishes the parameters for seric concentrations by fotocolorimetric tecnics, as well as the distal ileum, pro-inflamatory and antiinflamatory mediators levels, the mesenteric lymphatic nodes and liver by enzymatic inmunotest (enzyme-linked immunosorbent assay: ELISA). Finally we perform an hepatic histopathology test and Red Syrius stain to quantify the hepatic fibrosis area.Same parameters were evaluated in sham-operated rats SO (n=20) and in microsurgycal cholestatic rats MC (n=20) which were treated with ketotifen (10 mg/kg/day; oral) from 24 hours previous to surgery to the whole postoperatory period (8-9 weeks). Results: Cholestatic rats showed ascitis, rising portal pressure (p<0.001), venous mesenteric vasculopaty and porto-sistemic colateral circulation with hepatosplenomegaly (p<0.001) and testicular atrophy (p<0.01). Furthermore, cholestatic rats (MC) shoed hiperbilirrubinemy (p<0.001), an increase of alcalin phosphatase (p<0.001), bile acids (p<0.001), aspartate-aminotransferase (p<0.001), cholesterol (p<0.001), triglicerids (p<0.05) and low density lipoproteins (LDL; p<0.001) and very low density lipoproteins (VLDL; p<0.001) with regard to sham-operated rats. On the other hand, in these rats we noticed hipoproteinemy (p<0.001) and hipoalbuminemy (p<0.001) and a decrease of seric high density lipoproteins concentration (HDL; p<0.05). Relative to splanchnic inflammatory response, in rats with cholestasis, we showed an increase of catalase in ileon (p<0.01) and a decrease in lymphatic mesenteric nodes; glutation-transferase and glutation-peroxidase also decreased in the ileum and liver, TNF-α increased in the ileum and in the lymphatic mesenteric nodes, IL-1β decreased in the ileum (p<0.05) and lymphatic mesenteric nodes and increased in the liver (p<0.05), IL-10 increased in the ileum (p<0.05), IL-4 increased in the ileum (p<0.05) and in the liver, IL-13 and IL-17A increased in the ileum and decreased in the lymphatic mesenteric nodes, chemoatractant macrophage protein (MCP-1) increased in the ileum (p<0.05) and decreased in the lymphatic mesenteric nodes and in the liver (p<0.01), transforming growth factor-β1 (TGF-β1) increased in the ileum and in the liver and decreased in the lymphatic mesenteric nodes. In cholestatic rats hepatic histopatological study showed necrosis and hepatocitary apoptosis associated with an intense bile epithelial proliferation and fibrosis (p<0.001). On the one hand, the treatment with ketotifen in rats with MC decreased ascites, corporal weight, hepato-esplenomegaly and total and direct bylirrubin and bile acids, with increase of the serum levels of total proteins and high density lipoproteins (HDL). As regards the inflammatory mediator concentrations in the splanchnic area, ketotifen decreased the levels of MCP-1 in the liver, TNF-α in the ileum and in the liver (p<0.05), IL-17A and IL-1β in the ileum (p<0.05). We observed higher levels of IL-4 and IL-10 in the liver and IL-13 in the ileum. "Conclusions": The relevance of this investigative study is based on the possibility of applying the results to a human clinical area, in which cirrhosis of many different etiologies induces currently an elevated morbidity. Particularly, the anti-inflamatory treatment with ketotifen could be useful in order to reduce secondary complications due to biliary chronic liver disease

Use of clinical and surgical videos to support teaching in the subject of human anatomy

Introduction: Innovation in medical teaching in recent years has undergone major changes. Traditionally, the teacher used to rely exclusively on words, the blackboard, and anatomical dissection. Nowadays, classes are supported by numerous tools with the help of the computer. Methods: In the Department of Human Anatomy of the Faculty of Medicine of our University, during the first 4-month period of the course, we introduced in the classes the projection of 13 short videos with an average duration of 2.33 min, from laparoscopic and open surgical interventions, endoscopic and radiological studies. We surveyed at the end of the first 4 months period to evaluate the student´s opinions of the videos shown. Results: Regarding the usefulness of the video projection, 82.8% considered the projection very useful and 17.2% considered them somewhat useful. None of the students considered the projection of the videos to be useless for their learning. As for the duration of the videos, 97.3% considered the duration to be adequate. In the survey, the students freely expressed diverse opinions. Among others, they stated that they help to understand the real anatomy of the structures studied in 3 dimensions and that they help to review and consolidate theoretical knowledge of what has already been explained. They also said that they help with motivation in preclinical subjects. Others felt that the videos help to raise awareness of the practical usefulness of the subject in the context of the practice of medicine. Conclusion: We can assure that the projection of short prepared videos, taking sequences of open or laparoscopic surgical interventions and endoscopic or radiological studies, is very useful for improving the understanding of the subject of human anatomy, helping to clarify concepts and consolidating knowledge and increasing the student's motivation, as well as the performance in the study. Resumen: Introduccion: La innovación en la docencia médica en los últimos años ha sufrido grandes cambios. Tradicionalmente, el docente disponía exclusivamente de su palabra, de la pizarra y de la disección anatómica. Hoy en día las clases se apoyan numerosas herramientas con el apoyo del ordenador. Metodos: En el departamento de Anatomía humana de la Facultad de Medicina de nuestra Universidad, durante el primer cuatrimestre del curso introdujimos en las clases la proyección de 13 videos cortos con una duración media de 2,33 minutos, procedentes de intervenciones quirúrgicas laparoscópicas y abiertas, estudios endoscópicos y radiológicos. Realizamos una encuesta al final del cuatrimestre evaluando la opinión de los alumnos sobre los videos proyectados. Resultados: Respecto a la utilidad de la proyección de los videos, el 82,8% consideró muy útil la proyección y el 17,2% las consideró algo útiles. Ninguno de los alumnos consideró que la proyección de los videos fuera inútil para su aprendizaje. En cuanto a la duración de los videos al 97,3% les pareció que la duración era adecuada. En la encuesta los alumnos manifestaron libremente diversas opiniones. Entre otras, manifestaron que ayudan a comprender la anatomía real de las estructuras estudiadas en tres dimensiones y que ayudan a repasar y a asentar conocimientos teóricos de lo ya explicado. También que ayudan a la motivación con las asignaturas preclínicas. Otros opinaron que los videos ayudan a tomar conciencia de la utilidad práctica de la asignatura en el contexto del ejercicio de la medicina. Conclusion: Podemos asegurar que la proyección de videos cortos preparados, tomando secuencias de intervenciones quirúrgicas abiertas o laparoscópicas y de estudios endoscópicos o radiológicos, tiene una gran utilidad para la mejora de la comprensión de la asignatura de la anatomía humana, ayudando a aclarar conceptos y afianzar conocimientos e incrementando la motivación del alumno, así como el rendimiento en el estudio

The small bites technique for closure of abdominal midline incisions — a video vignette

peer-reviewed190 K

Multidisciplinary Approach to Treating Severe Acute Pancreatitis in a Low-Volume Hospital.

Background Up to 25% of patients with acute pancreatitis develop severe complications and are classified as severe pancreatitis with a high death rate. To improve outcomes, patients may require interventional measures including surgical procedures. Multidisciplinary approach and best practice guidelines are important to decrease mortality. Methods We have conducted a retrospective analysis from a prospectively maintained database in a low-volume hospital. A total of 1075 patients were attended for acute pancreatitis over a ten-year period. We have analysed 44 patients meeting the criteria for severe acute pancreatitis and for intensive care unit (ICU) admittance. Demographics and clinical data were analysed. Patients were treated according to international guidelines and a multidisciplinary flowchart for acute pancreatitis and a step-up approach for pancreatic necrosis. Results Forty-four patients were admitted to the ICU due to severe acute pancreatitis. Twenty-five patients needed percutaneous drainage of peri-pancreatic or abdominal fluid collections or cholecystitis. Eight patients underwent endoscopic retrograde cholangiopancreatography for choledocholithiasis and biliary sepsis or pancreatic leakage, and one patient received endoscopic trans-gastric endoscopic prosthesis for pancreatic necrosis. Sixteen patients underwent surgery: six patients for septic abdomen, four patients for pancreatic necrosis and two patients due to abdominal compartment syndrome. Four patients had a combination of surgical procedures for pancreatic necrosis and for abdominal compartment syndrome. Overall mortality was 9.1%. Conclusion Severe acute pancreatitis represents a complex pathology that requires a multidisciplinary approach. Establishing best practice treatments and evidence-based guidelines for severe acute pancreatitis may improve outcomes in low-volume hospitals.pre-print158 K

Prophylactic mesh can be used safely in the prevention of incisional hernia after bilateral subcostal laparotomies.

Background The use of prophylactic mesh to prevent incisional hernia is becoming increasingly common in midline laparotomies and colostomies. The incidence of incisional hernia after subcostal laparotomies is lower than after midline incisions. Nevertheless, the treatment of subcostal incisional hernia is considered to be more complex. Currently, there are no published data about mesh augmentation procedures to close these laparotomies. Methods This was a longitudinal, prospective, cohort study of patients undergoing a bilateral subcostal laparotomy in elective operations. The mesh group was a group of patients operated consecutively between 2011 and 2013 with a prophylactic self-fixation mesh. The control group was selected from a retrospective analysis of patients operated between 2009 and 2010 and closed with a conventional protocol of 2-layer closure. The incidence of incisional hernia was recorded both clinically and radiologically for 2 years. Results A total of 57 patients were included in the control group and 58 in the mesh group. Most patients underwent gastric, hepatic, and pancreatic operations. Both groups were homogeneous in terms of their clinical and demographic characteristics. Operative time and hospital stay were similar in both groups. Both groups had a comparable rate of local and systemic complications. Ten patients (17.5%) in the control group developed an incisional hernia, and only 1 patient (1.7%) in the mesh group developed an incisional hernia (P = .0006). Conclusion The incidence of incisional hernia after a conventional closure of bilateral subcostal laparotomy is significant. The use of a mesh augmentation procedure for closing bilateral subcostal laparotomies is safe and may reduce the incidence of incisional hernia.pre-print1514 K